Experimental Gerontology 154 (2021) 111509

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Experimental Gerontology
journal homepage: www.elsevier.com/locate/expgero

Review

Sauna use as a lifestyle practice to extend healthspan

Rhonda P. Patrick a, *, Teresa L. Johnson b
a
FoundMyFitness, LLC, PO Box 99785, San Diego, CA 92169, USA
b
TLJ Communications, LLC, 36 Creek Harbour Blvd., Freeport, FL 32439, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Sauna use, sometimes referred to as “sauna bathing,” is characterized by short-term passive exposure to high
Cardiorespiratory fitness temperatures, typically ranging from 45 ◦ C to 100 ◦ C (113 ◦ F to 212 ◦ F), depending on modality. This exposure
Cardiovascular disease elicits mild hyperthermia, inducing a thermoregulatory response involving neuroendocrine, cardiovascular, and
Heat shock protein
cytoprotective mechanisms that work in a synergistic fashion in an attempt to maintain homeostasis. Repeated
Heat stress
sauna use acclimates the body to heat and optimizes the body's response to future exposures, likely due to the
Hormesis
Hyperthermia biological phenomenon known as hormesis. In recent decades, sauna bathing has emerged as a probable means
to extend healthspan, based on compelling data from observational, interventional, and mechanistic studies. Of
particular interest are the findings from large, prospective, population-based cohort studies of health outcomes
among sauna users that identified strong dose-dependent links between sauna use and reduced morbidity and
mortality. This review presents an overview of sauna practices; elucidates the body's physiological response to
heat stress and the molecular mechanisms that drive the response; enumerates the myriad health benefits
associated with sauna use; and describes sauna use concerns.

1. Introduction Finland. Sauna use, sometimes referred to as “sauna bathing,” is char­

The evolving field of aging research has undergone dramatic shifts in
recent decades, as the prevailing view of aging as a non-modifiable
inevitability has given way to the possibilities of extending lifespan
and, even more promising, healthspan. A widely accepted definition of
healthspan is the period of one's life spent in good health, free from the
chronic diseases and disabilities that commonly accompany aging
(Kaeberlein, 2018). Healthspan extension compresses the time spent in
ill health, shifting it to one's later years. Sauna use has emerged as a
probable means to increase lifespan and extend healthspan.
Bathing oneself in heat for the purposes of purification, cleansing,
and healing is an ancient practice, observed for thousands of years
across many cultures. Variations of its use appear today in the banyas of
Russia, the sweat lodges of the American Indians, and the saunas of
acterized by short-term passive exposure to high temperatures, typically
ranging from 45 ◦ C to 100 ◦ C (113 ◦ F to 212 ◦ F), depending on modality.
This exposure elicits mild hyperthermia, an increase in the body's core
temperature that induces a thermoregulatory response involving
neuroendocrine, cardiovascular, and cytoprotective mechanisms that
participate in restoring homeostasis and conditioning the body for
future stressors (Laukkanen et al., 2018a).
Compelling data from observational, interventional, and mechanistic
studies support the assertions that sauna use extends healthspan, and
multiple recent reviews have described the cardiovascular, neurological,
and metabolic benefits associated with sauna use (Brunt and Minson,
2021; Ely et al., 2018; Hunt et al., 2019; Pizzey et al., 2021). Of
particular interest are the findings from studies of participants in the
Kuopio Ischemic Heart Disease (KIHD) Risk Factor Study. This ongoing

Abbreviations: ADHD, attention deficit hyperactivity disorder; BDNF, brain-derived neurotrophic factor; BPA, bisphenol A; CHF, congestive heart failure; CRP, C-
reactive protein; CVD, cardiovascular disease; FOX, forkhead box protein; FOXO3, forkhead box protein O3; GLUT4, glucose transporter type 4; HRV, heart rate
variability; HO-1, heme oxygenase-1; HSP, heat shock protein; IL-10, interleukin-10; IL-6, interleukin-6; KIHD, Kuopio Ischemic Heart Disease Risk Factor Study;
LDL, low density lipoprotein; Nrf2, nuclear factor erythroid 2–related factor 2; PAD, peripheral artery disease; PVC, premature ventricular contraction; RH, relative
humidity; SIRT1, sirtuin 1.
* Corresponding author.
E-mail addresses: rhonda@foundmyfitness.com (R.P. Patrick), teresa@tljcommunications.net (T.L. Johnson).

https://doi.org/10.1016/j.exger.2021.111509
Received 18 May 2021; Received in revised form 16 July 2021; Accepted 2 August 2021
Available online 5 August 2021
0531-5565/© 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
R.P. Patrick and T.L. Johnson
prospective population-based cohort study of health outcomes in more
than 2300 middle-aged men from eastern Finland has identified asso­
ciations between sauna use and reduced risk for age-related impair­
ments, including cardiovascular disease, neurodegenerative disease,
metabolic dysfunction, and immunological decline.
The KIHD findings revealed that among men who reported using the
sauna 2–3 times per week, the risk of cardiovascular disease (CVD)
mortality was 27% lower than among men who reported using the sauna
only once weekly (Laukkanen et al., 2015b). Furthermore, these effects
were dose-dependent: Among men who reported using the sauna 4–7
times per week, the risk of CVD mortality was 50% lower than among
men who reported using the sauna only once weekly (Laukkanen et al.,
2015b). In addition, the risk of all-cause mortality was 40% lower
among frequent sauna users compared to infrequent users, independent
of conventional risk factors (Laukkanen et al., 2015b).
Noncausal mechanisms, including socioeconomic status and reverse
causation bias, have been proposed as contributors to the KIHD findings
(Kivimaki et al., 2015). Although differences in socioeconomic status
may influence sauna access and opportunities for use, the robust dose-
dependent associations observed between sauna bathing and sudden
cardiac death, coronary artery disease, and cardiovascular events in the
KIHD studies are indicative of genuine inverse associations (Laukkanen
et al., 2015a). Furthermore, the KIHD studies were conducted in
Finland, where sauna use is deeply rooted in the culture, and saunas are
readily accessible (Laukkanen et al., 2015a). Similarly, whereas reverse
causation bias figures prominently in observational studies and is a valid
concern when investigating links between cardiovascular disease and
lifestyle, the KIHD findings were adjusted for potential biases, including
lifestyle factors such as socioeconomic status, physical activity, and
cardiorespiratory fitness (Laukkanen et al., 2015a).
The KIHD studies also revealed that frequent sauna use was associ­
ated with reduced risk of developing age-related neurodegenerative
conditions such as dementia and Alzheimer's disease, in a dose-
dependent manner. Men who reported using the sauna 4–7 times per
week had a 66% lower risk of developing dementia and a 65% lower risk
of developing Alzheimer's disease, compared to men who reported using
the sauna only once weekly (Laukkanen et al., 2017). The health benefits
associated with sauna use extended to other aspects of mental health, as
well. Men participating in the KIHD study who reported using the sauna
4–7 times per week had a 77% reduced risk of developing psychotic
disorders, even after adjusting for the men's energy intake, socioeco­
nomic status, physical activity, and inflammatory status, as measured by
C-reactive protein (Laukkanen et al., 2018c).
2. Sauna practices overview
The term “sauna” is a Finnish word, and it typically refers to an
unpainted spruce- or pine-paneled room, with wooden benches made of
aspen, spruce, or obeche (Hannuksela and Ellahham, 2001). The pre­
ponderance of research related to sauna bathing has been conducted in
Finland or in regard to Finnish-style sauna practices. Not all saunas are
Finnish style, however, and saunas may differ according to their heat
source, relative humidity, and duration of use. Similarly, sauna practices
may differ by modality.
2.1. Heat source
Historically, saunas were heated by wood fires, a practice still
observed today in rural parts of Finland. Most modern saunas, however,
are heated by electric conventional or infrared heaters. Conventional
heaters warm the air to a high temperature, ranging from 70 ◦ C to 100 ◦ C
(158 ◦ F to 212 ◦ F), optimally at 80 ◦ C to 90 ◦ C (176 ◦ F to 194 ◦ F) at the
level of the user's face, and the heat of the warmed air transfers to the
body (Hannuksela and Ellahham, 2001; Kukkonen-Harjula and Kaup­
pinen, 2006). Infrared heaters emit thermal radiation, which heats the
body directly. They operate at lower temperatures than traditional
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Experimental Gerontology 154 (2021) 111509
saunas, at 45 ◦ C to 60 ◦ C (113 ◦ F to 140 ◦ F) (Beever, 2009). Infrared
heaters emit either near or far wavelengths. Near infrared heaters use
incandescent bulbs to produce thermal radiation of varying wave­
lengths, ranging from near-infrared wavelengths (primarily) to middle-
infrared wavelengths (to a lesser degree). Far infrared heaters use
ceramic or metallic heating elements that emit energy in the far-infrared
range, typically at wavelengths of approximately 10 μm (Beever, 2009).
2.2. Humidity
Saunas are generally classified as either dry or wet. In a dry sauna,
the relative humidity is low (10–20%) (Hannuksela and Ellahham,
2001). A common practice in Finland, called löyly, is to apply water to
the heater's rocks to slightly increase the humidity. The term “wet
sauna” is a misnomer, however, referring to a steam sauna, where the
humidity is extremely high (typically greater than 50%), which impairs
sweat evaporation (Pilch et al., 2014a). Due to its reduced evaporative
cooling, a wet sauna may feel subjectively hotter than a dry sauna and
elicits greater strains on the cardiovascular system (Pilch et al., 2014a).
2.3. Duration, temperature, and practices across modalities
Finnish-style sauna bathing involves 1–3 sessions of heat exposure
lasting 5–20 min each, interspersed with periods of cooling (Kukkonen-
Harjula and Kauppinen, 2006). Some cooling methods involve rolling in
snow or immersing in cold water, further stressing the cardiovascular
system (Vuori, 1988). The KIHD studies typically involved saunas that
were heated to a temperature of at least 78.9 ◦ C (174 ◦ F), with an
average duration of 14.5 min (range, 2 to 90 min). Sessions lasting 19
min or more elicited a more robust protective effect than 11 to 18 min on
lowering mortality rate (Laukkanen et al., 2015b).
Infrared sauna sessions are typically 15 to 30 min in duration
(Beever, 2009). A variant of infrared sauna use, called waon therapy,
originated in Japan. Waon therapy involves a two-step process wherein
participants engage in a 15- to 30-minute session of infrared heat
exposure in a sauna heated to approximately 60 ◦ C (140 ◦ F), followed by
a 30-minute session of lying supine (outside the sauna) while covered in
warm blankets, to raise the core body temperature approximately 1.0 ◦ C
to 1.2 ◦ C (1.8 ◦ F to 2 ◦ F) (Sobajima et al., 2015). Waon therapy is
associated with improvements in multiple aspects of cardiovascular
function (Miyata and Tei, 2010).
A clinical application of heat exposure that differs slightly from
sauna use is called whole-body hyperthermia, a therapeutic strategy
used to treat various medical conditions, including cancer, fibromyalgia,
and others (Hoffmann et al., 2016; Romeyke et al., 2015; van der Zee,
2002). Emerging evidence suggests that whole-body hyperthermia is
beneficial in treating depression (Janssen et al., 2016). Whole-body
hyperthermia employs radiation, convection, or conduction and is
typically administered in the clinical setting using a variety of methods,
such as the use of direct contact with a heated liquid (such as water or
wax), hot blankets or suits, heating coils, or specialized lamps that emit
infrared-A radiation in a confined area or chamber (Jia and Liu, 2010;
Milligan, 1984; Robins et al., 1994).
3. Physiological response to heat stress
Exposure to high temperature stresses the body, eliciting a rapid,
robust response that affects primarily the skin and cardiovascular sys­
tems (Fig. 1). The skin heats first, rising to approximately 40 ◦ C (104 ◦ F),
followed by changes in core body temperature, rising slowly from 37 ◦ C
to approximately 38 ◦ C (98.6 ◦ F to 100.4 ◦ F) and then increasing rapidly
to approximately 39 ◦ C (102.2 ◦ F) (Gravel et al., 2021; Kukkonen-Har­
jula and Kauppinen, 2006; Kunutsor et al., 2021; Mori et al., 2017;
Smolander and Kolari, 1985; Sohar et al., 1976). Cardiac output may
increase by as much as 60–70%, while the heart rate increases and the
stroke volume remains stable (Hannuksela and Ellahham, 2001;
R.P. Patrick and T.L. Johnson
Fig. 1. Physiological response to heat stress.
Heat stress increases core body temperature, promotes blood redistribution, and increases sweat production. Heart rate and cardiac output increase, while stroke
volume remains stable.
Kukkonen-Harjula and Kauppinen, 2006). Concurrently, approximately
50–70% of the body's circulation redistributes from the core to the skin
to facilitate sweating, driving fluid losses at a rate of approximately 0.6
to 1.0 kg per hour, averaging approximately 0.5 kg during a moderate
temperature (80 ◦ C to 90 ◦ C; 176 ◦ F to 194 ◦ F) Finnish-style sauna
session (Gravel et al., 2021; Hasan et al., 1966; Kauppinen, 1989;
Laukkanen et al., 2019a; Laukkanen et al., 2015b; Podstawski et al.,
2014; Sohar et al., 1976; Vuori, 1988). Acute heat exposure also induces
a transient increase in overall plasma volume to mitigate the decrease in
core blood volume. This increase in plasma volume provides a reserve
source of fluid for sweating, cools the body to prevent rapid increases in
core body temperature, and promotes heat tolerance (Fortney and
Miescher, 1994). Sweating also facilitates higher excretion of some
heavy metals including aluminum (3.75-fold), cadmium (25-fold), co­
balt (7-fold), and lead (17-fold), compared to elimination via urine
(Genuis et al., 2011).
Repeated sauna use acclimates the body to heat and optimizes the
body's response to future exposures, likely due to a biological phe­
nomenon known as hormesis, a compensatory defense response
following exposure to a mild stressor that is disproportionate to the
magnitude of the stressor. Hormesis triggers a vast array of protective
mechanisms that not only repair cell damage but also provide protection
from subsequent exposures to more devastating stressors (Mattson,
2008). Exercise is a form of hormetic stressor (Goto and Radak, 2009; Ji
et al., 2010; Radak et al., 2005, 2008a; Radak et al., 2008b; Radak et al.,
2017). Interestingly, many of the physiological responses to sauna use
(described in detail below) are remarkably similar to those experienced
during moderate- to vigorous-intensity aerobic exercise, and sauna use
has been proposed as an alternative to aerobic exercise for people who
are unable to engage in physical activity due to chronic disease or
physical limitations (Hoekstra et al., 2020; McCarty et al., 2009; Soba­
jima et al., 2013).
3.1. Molecular mechanisms involved in the heat stress response
The hormetic effects of heat stress are facilitated by molecular
mechanisms that mitigate protein damage and aggregation and activate
endogenous antioxidant, repair, and degradation processes. Many of
these responses are also triggered in response to moderate- to vigorous-
intensity exercise and include increased expression of heat shock pro­
teins, transcriptional regulators, and pro- and anti-inflammatory factors.
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Experimental Gerontology 154 (2021) 111509
3.1.1. Heat shock proteins
One of the protective adaptive responses to heat stress is the
increased expression of heat shock proteins (HSPs). Heat-shock proteins
comprise a large, highly conserved family of proteins that are present in
all cells. Heat-shock proteins are also present in the extracellular envi­
ronment (Lyon and Milligan, 2019). They play prominent roles in many
cellular processes, including immune function, cell signaling, cell-cycle
regulation, and proteome homeostasis. Loss of proteome integrity is a
hallmark of the aging process (Lopez-Otin et al., 2013), and intrinsically
disordered or damaged, dysfunctional proteins are common features in
age-related diseases such as cardiovascular and neurodegenerative dis­
eases (Cheng et al., 2006). Increased expression of HSPs prevents protein
disorder and aggregation by repairing proteins that have been damaged,
and animal evidence suggests that HSPs may offer protection against
neurodegenerative diseases (Leak, 2014) (Fig. 2). Heat shock proteins
also moderate muscle atrophy (Fig. 2). Findings from a small interven­
tion study in rodents demonstrated that local heat application during an
immobilization period decreased muscle atrophy by 37% compared to a
sham treatment. The muscle-sparing effects of heat exposure were
attributed in part to marked increases in expression of HSP70 and HSP90
(25 ± 6.6 and 20 ± 7.4%, respectively), a finding that has been
demonstrated in other work, as well (Hafen et al., 2019; Senf et al.,
2008) (Fig. 2). Furthermore, HSPs are associated with human longevity.
A population-based association study of Danish nonagenarians demon­
strated that female carriers of single nucleotide polymorphisms (SNPs)
in specific gene regions of the HSP70 gene that increase the gene's sta­
bility and activity live approximately one year longer than non-carriers
(Singh et al., 2010).
Under stressful environmental conditions, cellular proteins can un­
fold or become damaged, impairing their normal functions, and further
increasing their vulnerability to change. During exposure to environ­
mental stressors such as temperature extremes (Amorim et al., 2015;
Sandstrom et al., 2009; Staib et al., 2007), reduced nutrient levels
(Ehrenfried et al., 1996; Heydari et al., 1993; Raynes et al., 2012),
bioactive dietary components (Moura et al., 2018), or hypoxia (Zhong
et al., 2000), cells increase expression of HSPs to stabilize unfolded
proteins and repair or re-synthesize damaged proteins.
Heat stress, in particular, robustly increases intracellular levels of
HSPs in humans (Yamada et al., 2007) (Fig. 3). For example, after
healthy men and women sat in a heat stress chamber for 30 min at 73 ◦ C
(163.4 ◦ F), their HSP72 levels increased by 49% (Iguchi et al., 2012). In
a different study, in which healthy men and women were exposed to
deep tissue heat therapy for six days, participants' HSP70 and HSP90
R.P. Patrick and T.L. Johnson
Fig. 2. Heat shock proteins provide protection against cellular stress.
Heat stress promotes increased expression of heat shock proteins (HSPs), which prevent protein disorder and aggregation by repairing proteins that have been
damaged, providing protection against chronic diseases. Increased expression of HSPs also slows muscle atrophy and promotes longevity.
levels increased 45% and 38%, respectively (Hafen et al., 2018). In
addition, their mitochondrial biogenesis biomarkers improved, and
their mitochondrial respiratory capacity increased by 28%, compared to
baseline levels. Increased levels of HSPs are sustained over time and
occur more rapidly in heat acclimated individuals, suggesting that heat
acclimation induces whole-body adaptations that increase heat toler­
ance, resulting in protective cellular adaptations (Yamada et al., 2007).
3.1.2. Nuclear factor erythroid 2–related factor 2
Nuclear factor erythroid 2–related factor 2 (Nrf2) is a key regulator
of the cellular antioxidant response. Upon activation, Nrf2 translocates
from the cytoplasm to the nucleus, leading to the orchestrated regula­
tion of a vast network of genes with cytoprotective, antioxidant, and
anti-inflammatory functions and providing protection against oxidative
stress, electrophilic stress, and chronic inflammation, the underlying
causes of many age-related chronic diseases (Pawelec et al., 2014;
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Experimental Gerontology 154 (2021) 111509
Fig. 3. Heat stress activates heat shock proteins.
Heat stress robustly activates heat shock proteins
(HSP), resulting in higher intracellular concentrations
of HSPs. This activation occurs within 30 min of heat
exposure and is sustained over time. Basal HSP con­
centrations are higher in heat-acclimated individuals,
suggesting that heat acclimation induces whole-body
adaptations that increase heat tolerance, resulting in
protective cellular adaptations.
Vomund et al., 2017). Application of whole-body hyperthermia (which
would elicit effects similar to those encountered with sauna use)
increased Nrf2 mRNA (Ihsan et al., 2020). Heat exposure activates Nrf2,
thereby upregulating the HSP heme oxygenase-1 (HO-1), which breaks
down heme to generate carbon monoxide and bilirubin (Lin and Yang,
2009; Yet et al., 2002). The downstream effect of HO-1 upregulation
includes inhibition of the expression of several pro-inflammatory mol­
ecules involved in the pathophysiology of cardiovascular disease,
including E-selectin, vascular cell adhesion molecule-1, and intercellular
adhesion molecule-1 (Lin and Yang, 2009).
3.1.3. Interleukin-6 and interleukin-10
Inflammation is a highly conserved element of the mammalian im­
mune response, but chronic low-grade inflammation is a fundamental
driver of many chronic disease processes (Michaud et al., 2013). Main­
taining the appropriate balance of pro- and anti-inflammatory factors is
R.P. Patrick and T.L. Johnson
crucial for the development and subsequent resolution of an inflamma­
tory response. The pathways that maintain this balance become dysre­
gulated with age, contributing to an inflammatory bias wherein innate
responses dominate, eliciting a state of chronic inflammation (Pawelec
et al., 2014). Interleukin-6 (IL-6) is a pro-inflammatory cytokine that
plays an important role in the regulation of central homeostatic and
immunological processes (Gabay, 2006). However, IL-6 also exerts anti-
inflammatory properties via its activation of interleukin-10 (IL-10), a
potent anti-inflammatory cytokine (Ahmed and Ivashkiv, 2000).
Whereas acute elevation of IL-6 is generally considered favorable,
chronic elevation is indicative of chronic inflammation. Exercise and
sauna use, which both elevate core body temperature, acutely increase
IL-6 and IL-10 plasma levels and IL-10 expression levels (Hoekstra et al.,
2020; Raison, 2017; Windsor et al., 2018; Zychowska et al., 2018).
4. Sauna bathing may extend healthspan
4.1. Promotion of cardiovascular health
Heat exposure induces protective responses that promote cardio­
vascular health. Some of these responses recapitulate those experienced
during exercise. For example, heart rate may increase up to 100 beats
per minute during moderate-temperature sauna bathing sessions and up
to 150 beats per minute during hotter sessions, similar to the increases
observed during moderate- to vigorous-intensity physical exercise
(Kukkonen-Harjula et al., 1989; Taggart et al., 1972). In a study
involving 19 healthy adults in which the cardiac responses to a single
25-minute sauna session were compared to those elicited by moderate
physical exercise, the cardiac loads were nearly equivalent, with par­
ticipants' heart rate and blood pressure increasing immediately in both
scenarios and dropping below baseline measurements taken pre-sauna
or -exercise (Ketelhut and Ketelhut, 2019). Like exercise, regular
sauna use generally decreases systolic and diastolic blood pressure
(Gayda et al., 2012; Laukkanen et al., 2018b; Zaccardi et al., 2017);
increases left ventricular ejection fraction and reduces left ventricular
ejection time (Blum and Blum, 2007; Lee et al., 2018; Ohori et al., 2012);
enhances arterial compliance (Lee et al., 2018; Li et al., 2020); and
improves flow-mediated dilation, a measure of endothelial function
(Imamura et al., 2001; Ohori et al., 2012) (Fig. 4).
Fig. 4. Long-term sauna use protects against cardiovascular disease.
Long-term sauna use induces protective responses against the pathological processes that drive cardiovascular disease and related disability by decreasing resting
systolic and diastolic blood pressure; increasing left ventricular ejection fraction and reducing left ventricular ejection time; enhancing arterial compliance; and
improving flow-mediated dilation, a measure of endothelial function.
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Experimental Gerontology 154 (2021) 111509
4.2. Protection against cardiovascular disease
Findings from the Global Burden of Disease Study indicate that 17.9
million people died from cardiovascular diseases in 2016 (Roth et al.,
2017). A growing body of evidence suggests that cardiovascular disease
is largely preventable via implementation of healthy lifestyle behaviors
such as exercise, healthy diet, and stress management (Buttar et al.,
2005; Claas and Arnett, 2016; Yusuf et al., 2004). Sauna use has
emerged as a healthy lifestyle behavior and primary prevention strategy
that may reduce the risk of cardiovascular disease and related mortality.
4.2.1. Cardiovascular disease-related mortality
The KIHD studies demonstrated dose-dependent cardiovascular
benefits associated with the frequency and duration of sauna use.
Whereas the risk for sudden cardiac death was 22% lower for men using
the sauna 2–3 times per week, the risk was 63% lower for men who used
the sauna 4–7 times per week, compared to men who used the sauna 1
time per week. The risk for fatal coronary heart disease was 23% lower
for men using the sauna 2–3 times per week and 48% lower for men
using the sauna 4–7 times per week, compared to men using the sauna 1
time per week. The risk for fatal cardiovascular disease was 27% lower
for men who used the sauna 2–3 times a week and 50% lower for men
who used the sauna 4–7 times a week, compared to men who used the
sauna 1 time per week. Similarly, longer duration sauna sessions were
associated with a more robust effect on lowering mortality rate relative
to shorter sessions. For example, the risk for sudden cardiac death
among men was 7% lower among those whose sauna sessions were 11
min or less and was 52% lower among those whose sauna sessions were
19 min or more.
Additionally, aerobic exercise in combination with frequent sauna
use has a synergistic effect on lowering cardiovascular-related mortality
and all-cause mortality. The strongest reductions in mortality were
found in people with high cardiorespiratory fitness and high frequent
sauna bathing, followed by high cardiorespiratory fitness and low
frequent sauna bathing, and then low cardiorespiratory fitness and high
frequent sauna bathing. These reductions were more strongly associated
with lower mortality outcomes compared with the separate associations
for each exposure (Kunutsor et al., 2018).
R.P. Patrick and T.L. Johnson
4.2.2. Congestive heart failure
Congestive heart failure (CHF) is a complex clinical syndrome that
arises from structural or functional cardiac disorders that impair ven­
tricular function (Hunt et al., 2001). The condition leads to impaired
blood flow to the heart and peripheral tissues with subsequent func­
tional losses, dyspnea, edema, and left ventricular hypertrophy. Treat­
ment is often limited to pharmaceutical, nutritional, or palliative care.
Findings from a prospective, multicentered, randomized controlled trial
involving 149 patients with advanced CHF demonstrated that 2 weeks of
waon therapy improved the patients' B-type natriuretic peptide levels,
endurance, cardiothoracic ratio, and disease status compared to those
who received standard medical care (Tei et al., 2016). In a different
randomized controlled trial involving 30 CHF patients with frequent
premature ventricular contractions (PVCs), 2 weeks of infrared dry
sauna (waon therapy) reduced the number of PVCs the patients expe­
rienced in a 24-h period (from a baseline of 3161 ± 1104 to 848 ± 415,
post-therapy). A control group that received conventional medical
therapy showed no significant changes (Kihara et al., 2004).
4.2.3. Ischemic heart disease
Ischemic heart disease, the most common cause of death in most
western countries, is characterized by impaired myocardial perfusion
(Steenbergen and Frangogiannis, 2012). A randomized controlled trial
that examined the effects of sauna use in 24 patients with ischemic heart
disease with chronic total coronary artery occlusion who had not
responded to non-surgical procedures and had failed or were not candi­
dates for percutaneous coronary intervention demonstrated that 15 waon
sessions given over a 3-week period improved the patients' vascular
endothelial function as measured by flow-mediated dilation of the
brachial artery. No significant improvements were observed in the con­
trol group that received standard medical care (Sobajima et al., 2013).
4.2.4. Peripheral artery disease
Peripheral artery disease (PAD) is characterized by arterial athero­
sclerotic lesions of the aorta, iliac artery, and lower extremities (Olin
et al., 2016). A pilot trial involving 20 patients with PAD who received
50 waon sessions over a period of 10 weeks demonstrated improvements
in pain levels, walking endurance, and lower extremity blood flow (Tei
et al., 2007). A similar randomized controlled trial involving 21 patients
with PAD showed comparable improvements (Shinsato et al., 2010).
4.2.5. Dyslipidemia
Dyslipidemia is a strong predictor of cardiovascular disease risk. Two
small studies have demonstrated that regular sauna use modulates
serum cholesterol and lipoproteins in healthy adults. Women who were
exposed to seven 30-minute sauna baths over a period of 2 weeks
exhibited reduced total plasma cholesterol concentrations (from 4.47 ±
0.85 mmol/L to 4.25 ± 0.93 mmol/L) and reduced plasma low-density
lipoprotein (LDL) concentrations (from 2.83 ± 0.80 mmol/L to 2.69
± 0.83 mmol/L), assessed immediately after the final sauna session
(Pilch et al., 2014b). Similarly, men who were exposed to ten 45-minute
sauna baths over a period of 3 weeks exhibited reduced total blood
cholesterol concentrations (from 4.50 ± 0.66 mmol/L to 4.16 ± 0.54
mmol/L) and reduced blood LDL concentrations (from 2.71 ± 0.47
mmol/L to 2.43 ± 0.35 mmol/L), assessed immediately after the final
session (Gryka et al., 2014).
4.2.6. Hypertension
Hypertension, defined as a systolic pressure of 130 mm Hg or higher,
or a diastolic pressure of 80 mm Hg or higher, is a robust predictor of
future incidence of stroke, coronary heart disease, heart attack, heart
failure, and cardiovascular-related death (Whelton et al., 2018). Central
to the pathophysiology of hypertension is the loss of arterial compliance,
which can have far-reaching effects on multiple organ systems,
including the brain and kidneys. A common element among sauna users,
however, is lower incidence of hypertension through improvements in
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Experimental Gerontology 154 (2021) 111509
arterial compliance. For example, men who reported using the sauna
2–3 sessions every week were found to have a 24% lower risk of
developing hypertension, and men who reported using the sauna 4–7
times per week had a 46% lower risk for developing hypertension,
compared to men who used the sauna only 1 time per week (Zaccardi
et al., 2017). In fact, a single sauna session has been shown to lower
blood pressure and improve arterial compliance when assessed imme­
diately after completion of the session. These effects were sustained
during a 30-minute recovery period (Lee et al., 2018). As such, sauna use
may serve as a non-pharmacological means to address, or even prevent,
hypertension.
4.2.7. Endothelial dysfunction
Endothelial dysfunction is characterized by decreased secretion of
vasodilators and/or increased secretion of vasoconstrictors. This
imbalance leads to impaired endothelium-dependent vasodilation, a
common element in the pathophysiology of congestive heart failure.
However, two weeks of sauna therapy in patients with congestive heart
failure improved endothelial function, as evidenced by significant in­
creases in flow-mediated dilation; and improved cardiac function, as
evidenced by significant decreases in concentrations of brain natriuretic
peptide (Kihara et al., 2002).
4.2.8. Left ventricular dysfunction
Dysfunction of the heart's left ventricle sets in motion a cascade of
compensatory mechanisms that promote organ-level structural changes
and elicit system-level hormonal adaptations. It is a common occurrence
after myocardial infarction and markedly increases the risk of ischemic
stroke (Hays et al., 2006). Both single-session and long-term sauna use
(5 days per week for 4 weeks) improved left ventricular function in men
with congestive heart failure via reduced afterload associated with
thermal vasodilation. Consequently, sauna use may have therapeutic
value for treating late-stage cardiovascular disease (Tei and Tanaka,
1996; Thomas et al., 2016).
4.2.9. Heart rate variability
Heart rate variability (HRV) is a measure of the variation in time
between heartbeat intervals. Opposing inputs from the sympathetic and
parasympathetic branches of the autonomic nervous system work in
tandem to regulate heart rate and modulate HRV. Whereas increased
sympathetic activity or decreased parasympathetic activity accelerates
heart rate and lowers HRV, decreased sympathetic activity or increased
parasympathetic activity slows heart rate and increases HRV. A higher
HRV, or greater variability between heartbeats, is an indicator of auto­
nomic nervous system health; as such, HRV is a well-established marker
of cardiovascular risk (Acharya et al., 2006; Hillebrand et al., 2013).
Aerobic exercise induces potent autonomic nervous system responses in
the cardiovascular system and, in turn, strongly influences HRV both
during and after training (Hautala et al., 2009).
Evidence suggests that sauna use elicits similar effects to exercise to
increase HRV via modulation of the autonomic nervous system. Sauna
use holds promise as a therapeutic strategy in the treatment of cardiac
arrhythmias, a common feature of CHF (Franciosi et al., 2017; Leim­
bach et al., 1986). A study involving patients with CHF who experi­
enced 200 or more premature ventricular contractions (PVCs) per 24-h
period, sauna exposure (15 min per day, followed by 30 min of bedrest
for 5 days per week for 2 weeks) elicited increases in HRV and mark­
edly reduced the number of PVCs (Kihara et al., 2004). Furthermore, a
single, 30-minute sauna session in 93 men with at least 1 cardiovas­
cular risk factor elicited significant favorable effects on multiple var­
iables associated with HRV. Specifically, the men's HRV and
parasympathetic activity increased, and their resting heart rate was
lower after sauna use (68/min) compared to before sauna use (77/min)
(Laukkanen et al., 2019b).
R.P. Patrick and T.L. Johnson
4.2.10. Inflammation
Inflammation is a critical element of the body's immune response,
but chronic inflammation plays a key role in the development of many
chronic diseases, including cancer, cardiovascular disease, and diabetes.
Markers of inflammation increase with aging. Exercise provokes an in­
flammatory response driven by the release of the pro-inflammatory
cytokine IL-6, which in turn elicits a counter response driven via the
release of anti-inflammatory cytokines IL-1ra and IL-10 (Hoekstra et al.,
2020; Pedersen and Febbraio, 2008; Petersen and Pedersen, 2005;
Windsor et al., 2018). This exercise-induced response is due in part to
the increase in core body temperature that accompanies exertion and
likely explains some of the benefits associated with regular exercise
(Costello et al., 2018; Starkie et al., 2005). Passive strategies that induce
increases in body temperature may similarly reduce inflammation and
may be particularly well-suited for individuals who are unable to
participate in regular exercise due to physical or cognitive limitations
(Hoekstra et al., 2020).
C-reactive protein (CRP), an acute phase reactant, also participates
in the body's inflammatory cascade. Elevated CRP is associated with the
development of atherosclerosis, loss of arterial compliance, and greater
incidence of cardiovascular events (Hage, 2014). Sauna use reduces
blood levels of CRP, however. In a study of more than 2000 men living in
Finland, CRP levels were inversely related to the frequency of sauna
bathing in a dose-response fashion, with lower levels linked to greater
frequency (Laukkanen and Laukkanen, 2018). As previously described,
IL-10 is a potent endogenous anti-inflammatory protein. In a study
involving 22 healthy male athletes and non-athletes who received two
15-minute sauna sessions at 98.2 ◦ C (208.7 ◦ F) separated by a 5-minute
cool shower, the men's resting IL-10 levels increased, and this adaptation
occurred faster in the athletes. A slight increase in some HSPs was also
observed (Zychowska et al., 2018).
4.3. Cognitive and mental health
4.3.1. Enhanced neurogenesis
Heat stress and exercise increase the expression of brain-derived
neurotrophic factor (BDNF) (Kojima et al., 2018), a protein that acts
on neurons in the central and peripheral nervous systems, to promote
the growth of new neurons. BDNF modulates neuronal plasticity and
ameliorates anxiety and depression from early-life stressful events
(Maniam and Morris, 2010). It is active in the hippocampus, cortex,
cerebellum, and basal forebrain – areas involved in learning, long term
memory, and executive function. BDNF is also produced in exercising
muscle tissue, where it plays a role in muscle repair and the growth of
new muscle cells (Pedersen, 2013).
Whole-body hyperthermia administered via hot water baths elicits
robust increases in serum BDNF levels. An investigation of the effects of
head-out immersion in hot water demonstrated that serum BDNF levels
increased 66% following a 20-minute immersion in 42 ◦ C (108 ◦ F)
water. Core body temperature increased to 39.5 ◦ C (103.1 ◦ F), while
plasma cortisol levels dropped significantly over the immersion period.
Serum BDNF remained significantly higher than before immersion for
15 minutes post-immersion (Kojima et al., 2018).
4.3.2. Neurodegenerative diseases
Findings from a large observational study of middle-aged men living
in Finland demonstrated that men who used the sauna 4–7 times per
week had a 65% reduced risk of developing Alzheimer's disease,
compared to men who used the sauna only 1 time per week (Laukkanen
et al., 2015b). There may be multiple mechanisms by which frequent
sauna use may stave off neurodegenerative diseases. Normal cognitive
function is dependent upon sufficient blood flow to the brain and pe­
ripheral nervous system. For this reason, cardiovascular diseases and
cognitive decline are common comorbidities. For example, hypertension
alters the microarchitecture of cerebral blood vessels and impairs blood
flow to the brain. Poor cerebral blood flow is commonly observed in
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Experimental Gerontology 154 (2021) 111509
mice and humans and may contribute to impaired amyloid-beta clear­
ance, thereby accelerating the progression of Alzheimer's disease
(Iadecola, 2004). In addition, heat exposure increases the production of
BDNF to promote neurogenesis. Lastly, heat shock proteins, which in­
crease following sauna use, demonstrate critical roles in preventing
Alzheimer's disease, as described previously (Leak, 2014).
4.3.3. Depression
Elevated biomarkers of inflammation are commonly observed in
individuals who have depression (Dinan, 2009). Chronic activation of
the body's inflammatory response system promotes the development of
depressive symptoms and induces changes in brain and neuroendocrine
function, suggesting that strategies that induce anti-inflammatory
pathways may reduce symptoms of depression. Preclinical studies
have found that exogenous administration of the anti-inflammatory
cytokine IL-10 can improve depressive symptoms (Roque et al., 2009;
Worthen et al., 2020).
Sauna use has been shown to reduce symptoms of depression. In a
randomized controlled trial involving 28 individuals diagnosed with
mild depression, participants who received 4 weeks of sauna sessions
experienced reduced symptoms of depression, such as improved appe­
tite and reduced somatic complaints and anxiety, compared to the
control group, which received bedrest instead of sauna therapy (Masuda
et al., 2005). In a randomized, double-blind study of 30 healthy adults
diagnosed with depression, participants who were exposed to a single
session of whole-body hyperthermia in which core body temperature
was elevated to 38.5 ◦ C (101.3 ◦ F) experienced an acute antidepressant
effect that was apparent within 1 week of treatment and persisted for 6
weeks after treatment (Janssen et al., 2016). Some of these benefits on
mood may be due to the effects of heat stress on acutely increasing
plasma levels of pro-inflammatory IL-6 and anti-inflammatory IL-10,
similar to effects observed following exercise (Miller and Raison, 2016;
Windsor et al., 2018; Zychowska et al., 2018). Interestingly, a small
study in which individuals diagnosed with major depressive disorder
received whole-body hyperthermia demonstrated that the participants'
antidepressant response correlated with reductions in core body tem­
perature in the 5 days post treatment (Hanusch et al., 2013).
4.4. Beta-endorphins and the opioid system
Beta-endorphins are endogenous opioids that are produced and
stored primarily in the anterior pituitary gland of the brain. They play
important roles in pain management and reward circuitry. Evidence
suggests that beta-endorphins are responsible in part for the euphoric or
pleasant sensations that commonly occur in response to exercise (Basso
and Suzuki, 2017). The binding of beta-endorphins to mu-opioid re­
ceptors on nerve cells suppresses the release of pain-promoting sub­
stances in the brain. Sauna use promotes robust increases in beta-
endorphins (Jezova et al., 1985; Kukkonen-Harjula and Kauppinen,
1988; Vescovi et al., 1992).
Dynorphin is an opioid that is generally responsible for the sensation
of dysphoria, a profound sense of unease or dissatisfaction. Dynorphin
may also help mediate the body's response to heat, helping the body to
cool (Xin et al., 1997). Heat activates neurons in the dorsal lateral
parabrachial nucleus that express dynorphin (Tan and Knight, 2018).
The activation of this thermosensory pathway elicits heat-defense re­
sponses in which the binding of dynorphin to kappa-opioid receptors
triggers cellular events that promote pain and distress (Nakamura and
Morrison, 2010). The heat stress caused by sauna use may promote
dynorphin release, which may be responsible for the general sense of
discomfort experienced during heat exposure. Interestingly, in a bio­
logical feedback response that occurs after dynorphin binds to the
kappa-opioid receptor, mu-opioid receptors become more sensitized to
beta-endorphins (Narita et al., 2003). Thus, repeated sauna use may
sensitize mu-opioid receptors to endorphins.
R.P. Patrick and T.L. Johnson
4.5. Endocrine system
4.5.1. Growth hormone
Growth hormone secretion progressively declines with age and may
contribute to sarcopenic obesity and frailty (Garcia et al., 2000). Sauna
use promotes transient growth hormone release, which varies according
to time, temperature, and frequency of exposure. For example, two 20-
minute sauna sessions at 80 ◦ C (176 ◦ F) separated by a 30-minute
cooling period elevated growth hormone levels 2-fold over baseline,
but two 15-minute sauna sessions at 100 ◦ C (212 ◦ F) dry heat separated
by a 30-minute cooling period resulted in a 5-fold increase in growth
hormone (Hannuksela and Ellahham, 2001; Kukkonen-Harjula et al.,
1989). Interestingly, repeated exposure to whole-body heat treatment
through sauna use has an even more profound effect on boosting growth
hormone immediately afterward: Seventeen men and women who were
exposed to two 1-h sauna sessions at 80 ◦ C (176 ◦ F) dry heat (typical
Finnish-style sauna) per day for 7 days exhibited a 16-fold increase in
growth hormone levels by the third day (Leppaluoto et al., 1986). The
growth hormone effects generally persisted for a few hours post-sauna
(Hannuksela and Ellahham, 2001). It is noteworthy, however, that
sauna use and exercise work synergistically to significantly elevate
growth hormone when used together (Ftaiti et al., 2008).
4.6. Immune function and respiratory infection
A prominent feature of aging is impaired immune function. Evidence
suggests that HSPs play critical roles in preserving immunological
resilience. They serve as endogenous danger signals, facilitate the ac­
tivities of antigen-presenting cells, bind pathogen-associated molecular
pattern molecules, and modulate immune cell signaling, thus regulating
aspects of both the innate and adaptive immune response (Osterloh and
Breloer, 2008).
Sauna use is associated with reduced risk of developing certain
chronic or acute respiratory illnesses, including pneumonia (Kunutsor
et al., 2017). Findings from the KIHD studies indicate that among men
who reported using the sauna 2–3 times per week, the risk of developing
pneumonia was 27% lower than among men who reported using the
sauna only 1 time per week or not at all. The risk of developing pneu­
monia among men who reported using the sauna 4–7 times per week was
41% lower than those who reported using the sauna only 1 time per
week or not at all (Kunutsor et al., 2017).
Evidence suggests that both traditional Finnish-style sauna use and
waon therapy elicit improvements in respiratory function in men with
obstructive pulmonary disease (Cox et al., 1989; Umehara et al., 2008). In
addition, sauna bathing demonstrates effectiveness in reducing the inci­
dence of common colds. When 25 healthy adults used the sauna 1–2 times
per week for 6 months, participants experienced fewer colds than a con­
trol group that did not use the sauna or other hyperthermic treatments. It
is noteworthy that the protective effects of sauna use in this group did not
manifest until the third month of treatment (Ernst et al., 1990).
The beneficial effects of sauna use on respiratory health may be
related to decreases in oxidative stress and inflammation associated with
hyperthermia or via direct effects on lung tissue (Sutkowy et al., 2014).
For example, frequent sauna use may decrease pulmonary congestion
and promote other aspects of healthy lung function, including vital ca­
pacity, tidal volume, minute ventilation, and forced expiratory volume
(Laitinen et al., 1988).
Other findings point to the effects of sauna use on the immune system
and heat shock proteins. A single session of Finnish-style sauna
increased white blood cell, lymphocyte, neutrophil, and basophil counts
in both trained and non-trained athletes (Pilch et al., 2013). Further­
more, as described above, heat stress promotes the production of heat
shock proteins, such as HSP70. Maximal HSP70 protein levels in human
lung epithelial cells demonstrate a linear relationship with heat expo­
sure, increasing approximately 50% per degree Celsius at a range be­
tween 37 ◦ C and 41 ◦ C (98.6 ◦ F and 105 ◦ F) (Singh and Hasday, 2013).
8
Experimental Gerontology 154 (2021) 111509
Increasing evidence suggests that certain HSPs play roles in both innate
and adaptive immunity (Wallin et al., 2002). For example, HSPs can
directly stimulate innate immune responses, such as the maturation and
activation of dendritic cells and the activation of natural killer cells,
suggesting there is a direct role for HSPs in regulating the innate im­
mune response (Wallin et al., 2002). Cellular release of HSP70 can
stimulate innate immune responses via feedback mechanisms involving
toll-like receptors 2 and 4 (Singh and Hasday, 2013).
4.7. Physical fitness
Physical fitness is a critical component of human health and an in­
dependent predictor of mortality (Park et al., 2012). Multiple perfor­
mance- and health-related measures are determinants of physical
fitness, including cardiorespiratory fitness; musculoskeletal strength and
endurance; flexibility; and body composition (Wilder et al., 2006), but
these attributes typically decline with aging. For example, maximal
oxygen consumption (VO2 max) declines approximately 10% per
decade of life, regardless of activity level (Hawkins and Wiswell, 2003).
Maintaining physical fitness in older adults is associated with pre­
served cognitive function, reduced frailty, and overall improved quality
of life (Deary et al., 2006; Jeoung and Lee, 2015; Navarrete-Villanueva
et al., 2021; Park et al., 2012; Takata et al., 2010). Heat stress from
sauna use may modulate improvements in physical fitness by increasing
cardiorespiratory fitness and endurance and preserving muscle mass.
4.7.1. Increased endurance
A small intervention study investigated the effects of repeat sauna
use on endurance and other physiological effects in 6 male distance
runners. The findings showed that one 30-minute sauna session twice a
week for 3 weeks post-workout increased the time that it took for the
study participants to run until exhaustion by 32% compared to their
baseline (Scoon et al., 2007). These endurance improvements were
accompanied by a 7.1% increase in plasma volume and a 3.5% increase
in erythrocytes (Scoon et al., 2007). During exercise, erythrocytes
transport oxygen from the lungs to the body's tissues and deliver carbon
dioxide to the lungs for expiration. Increases in erythrocyte levels may
facilitate these processes and improve endurance.
4.7.2. Improved cardiovascular and thermoregulatory function
Regular sauna use improves cardiovascular and thermoregulatory
mechanisms during endurance exercise via heat acclimation. During
exercise, core body temperature increases, attenuating endurance and
accelerating exhaustion. Heat acclimation induces complex physiolog­
ical adaptations that improve thermoregulation, attenuate physiological
strain, and enhance athletic performance in hot environments. These
adaptations are mediated via improved cardiovascular and thermoreg­
ulatory mechanisms that reduce the deleterious effects associated with
elevated core body temperature, optimizing the body for subsequent
increases in core body temperature during future exercise.
In a small study involving 9 female athletes who sat for 20 min per
day for 5 days in a hot environment (50 ◦ C [122 ◦ F], in low humidity)
wearing a sauna suit to replicate sauna conditions, the women experi­
enced thermoregulatory and cardiovascular improvements as well as
reduced perceived strain compared to a control group (Mee et al., 2018).
Another randomized controlled trial found that endurance training in a
sauna suit led to improved performance and respiratory measures,
including VO2max. The authors speculated that the improved perfor­
mance time for the sauna suit group was due to improved VO2max and
increased capacity for thermoregulation. For example, they noted that
sweat rate during a heated 5 km time trial increased in the post-
intervention group but not the control group (Van de Velde et al. 2017).
Another investigation gauged the efficacy of supplementing normal
endurance training with intermittent post-exercise sauna bathing in 20
trained university athletes between the ages of 18 and 22 years. Partici­
pants completed 30-minute sauna sessions at 101◦ –108 ◦ C (214◦ –226 ◦ F)
R.P. Patrick and T.L. Johnson
3 times per week for 3 weeks, commencing within approximately 5 min of
engaging in low-intensity, continuous outdoor exercise. Heat tolerance
tests revealed that the sauna users' heart rate decreased 11 beats/min; skin
temperature decreased 0.8 ◦ C (1.4 ◦ F); and peak rectal temperature
decreased 0.2 ◦ C (0.36 ◦ F), compared to non-sauna users. Sauna users also
experienced improvements in VO2max and speed. Four additional weeks
of sauna exposure elicited changes in rectal temperature only (0.1 ◦ C,
1.8 ◦ F) (Kirby et al., 2020).
Improvements in thermoregulatory function are commonly observed
following heat acclimation. Heat exposure activates the sympathetic
nervous system, increasing peripheral blood flow and the sweat rate to
dissipate core body heat. After acclimation, sweating occurs at a lower
core temperature and the sweat rate is maintained for a longer period
(Costa et al., 2014). As previously described, heat acclimation also in­
creases plasma volume and stroke volume (Costa et al., 2014; Kukkonen-
Harjula et al., 1989). This results in reduced cardiovascular strain and
lowered heart rate for the same given workload (Costa et al., 2014).
These cardiovascular improvements have been shown to enhance
endurance in both highly trained and untrained individuals (Costa et al.,
2014; Garrett et al., 2012; Kukkonen-Harjula et al., 1989).
A single exposure to heat stress from a sauna also increased blood
flow to exercising muscles. One study found that a hand grip exercise
performed in a sauna at 65 ◦ C to 75 ◦ C (149 ◦ F to 167 ◦ F) resulted in a 2-
fold increase in blood flow in both the exercising and non-exercising
forearm compared to performing the exercise at room temperature
(Smolander and Louhevaara, 1992).
4.7.3. Muscle mass maintenance
Muscle loss occurs during the aging process but can also result from
disease or trauma. Although exercise can help combat muscle loss, some
medical conditions or physical limitations can make exercise difficult or
even impossible. Whole-body hyperthermia may preserve or increase
muscle mass and may also increase mitochondrial biogenesis. A small
study in healthy young individuals found that two 60-minute sessions of
whole-body hyperthermia at 44 ◦ C to 50 ◦ C (111 ◦ F to 122 ◦ F) and 50%
humidity, separated by one week, led to increased activity of the Akt/
mTOR biological pathway, a critical regulator in maintaining skeletal
muscle mass. It also increased the expression of HSPs and Nrf2, indic­
ative of mitochondrial biogenesis (Ihsan et al., 2020).
Muscular atrophy also commonly occurs with muscle immobilization
or disuse following injuries. Atrophy induces substantial strength losses,
especially during the first week of immobilization or disuse, due to
reduced protein synthesis and increased protein degradation (Alves
et al., 2013). Maintaining muscle mass requires balancing new protein
synthesis with existing protein degradation. While new protein synthesis
accompanies muscle use during exercise, protein degradation can occur
during both muscle use and disuse. Of critical importance, therefore, is
net protein synthesis. Heat acclimation, which can be achieved through
sauna use, may reduce the amount of protein degradation that occurs
during disuse by increasing expression of HSPs, reducing oxidative
damage, and promoting release of growth hormone (Hannuksela and
Ellahham, 2001; Kokura et al., 2007; Naito et al., 2000; Selsby et al.,
2007). Maintaining positive net protein synthesis also has special rele­
vance for recovery from injury since injury can tip the balance toward
protein degradation and away from protein synthesis in the muscles,
promoting muscle atrophy.
A small intervention study in humans found that daily heat treat­
ments applied locally to muscle during 10 days of immobilization pre­
vented the loss of mitochondrial function, increased HSP levels, and
attenuated skeletal muscle atrophy by 37% compared to a sham treat­
ment group (Hafen et al., 2019). These results have been replicated in
animal studies. For example, when rats received whole-body hyper­
thermia at 41 ◦ C (105.8 ◦ F) for 30 min or 60 min, hindlimb muscle at­
rophy during disuse decreased by 20% or 32%, respectively (Naito et al.,
2000; Selsby and Dodd, 2005). In another rodent study that investigated
the effects of heat stress, a 30-minute intermittent hyperthermic
9
Experimental Gerontology 154 (2021) 111509
treatment at 41 ◦ C for 7 days induced a robust expression of HSPs
(including HSP32, HSP25, and HSP72) in muscle, correlating with 30%
more muscle regrowth than a control group subsequent to a week of
immobilization (Naito et al., 2000; Selsby et al., 2007). This HSP in­
duction can persist for up to 48 h after heat shock (Selsby et al., 2007).
Heat acclimation causes a higher basal expression of HSPs (even when
not exercising) and a more robust induction upon elevation in core body
temperature (such as during exercise) (Kuennen et al., 2011; Moseley,
1997; Yamada et al., 2007). Heat shock proteins, described previously,
can prevent muscle protein damage by directly scavenging reactive
oxygen species and by supporting cellular antioxidant capacity through
their effects on maintaining the endogenous antioxidant glutathione
(Naito et al., 2000; Selsby et al., 2007). In addition, HSPs can repair
misfolded, damaged proteins, thereby ensuring proteins maintain their
proper structure and function (Naito et al., 2000; Selsby et al., 2007).
Furthermore, exposing mouse myoblasts to 42 ◦ C (106 ◦ F) for 30 min
enhanced the activity of transcription factors involved in myogenesis
(Obi et al., 2019). This may have special relevance for slowing age-
related sarcopenia, a progressive condition characterized by loss of
skeletal muscle mass and strength and a leading cause of functional
decline and loss of independence in older adults.
5. Sauna bathing concerns
5.1. Male fertility
Heat exposure has notable, but reversible, effects on male sperm and
fertility measures. In a study involving 10 healthy men who underwent
two 15-minute sauna sessions at 80 ◦ C to 90 ◦ C (176 ◦ F to 194 ◦ F) every
week for 3 months, the men experienced reduced sperm counts and
motility. These measures returned to normal, however, within 6 months
of sauna use cessation (Garolla et al., 2013).
5.2. Special populations
5.2.1. Pregnant women
Some central nervous system birth defects, such as anencephaly and
spina bifida, are linked with exposure to extreme heat during pregnancy.
However, in Finland, where the majority of women practice sauna
bathing at least once a week throughout their pregnancies, the incidence
of anencephaly is the lowest in the world (Rapola et al., 1978). Similarly,
observational studies conducted in Finland and the United States
showed no links between sauna use and higher incidence of cardiovas­
cular malformations, the most common form of birth defects (Kukkonen-
Harjula and Kauppinen, 2006).
The suggested teratogenic threshold for core body temperature in
pregnant women is 39.0 ◦ C (102.2 ◦ F) (Graham et al., 1998). A sys­
tematic review of 12 studies investigated the effects of heat stress from
exercise (land-based or water immersion) or passive modalities (hot
water bathing or sauna use) among 347 pregnant women. Among those
engaging in land-based or water immersion exercise, the highest mean
core body temperatures were 38.3 ◦ C (100.9 ◦ F) and 37.5 ◦ C (99.5 ◦ F),
respectively. Among women engaging in hot water bathing or sauna
use, the highest mean core body temperatures were 36.9 ◦ C (98.4 ◦ F)
and 37.6 ◦ C (99.7 ◦ F), respectively. The investigators concluded that
exercise and passive heat modalities did not increase core body tem­
peratures to teratogenic levels if performed within the following pa­
rameters: land-based exercise for up to 35 min at 80% to 90% of
maximum heart rate in 25 ◦ C (77 ◦ F) and 45% relative humidity (RH);
water immersion exercise at temperatures less than or equal to 33.4 ◦ C
(92.1 ◦ F) for up to 45 min; or sitting in hot baths (40 ◦ C; 104 ◦ F) or hot,
low humidity saunas (70 ◦ C; 158 ◦ F; 15% RH) for up to 20 min (Rav­
anelli et al., 2019). Evidence indicates that pregnant women with
toxemia exhibit increased resistance to blood flow in the uterine ar­
tery, potentially compromising fetal health, and should exercise
caution when using the sauna (Kukkonen-Harjula and Kauppinen,
R.P. Patrick and T.L. Johnson
2006). Women should consult with their physician during pregnancy
regarding sauna use.
5.2.2. Children
Children have less efficient thermoregulatory mechanisms than
adults due to critical differences in their anatomy and physiology. In
particular, they have lower sweat rates than adults, which can
compromise their ability to dissipate body heat through evaporation
(Gomes et al., 2013). Whether healthy children are more vulnerable to
hyperthermia has been called into question, however (Rowland, 2008;
Smith, 2019). Conversely, children with sinoatrial node disorders may
be at greater risk of fainting during the cool-down phase after sauna
bathing due to the sudden drop in blood pressure that often accompanies
cooling (Jokinen and Valimaki, 1991).
5.3. Other factors and contraindications
The sauna is generally well-tolerated and safe for most healthy in­
dividuals as well as for those with stable heart disease. Several studies
have shown that individuals with certain types of cardiovascular disease
may experience improvements in their symptoms and disease status
with sauna use (Hussain and Cohen, 2018). Because many of the phys­
iological responses to heat stress from sauna bathing are similar to
moderate aerobic activity, using the sauna may be especially beneficial
for individuals with various injuries and disabilities such as sports
injury, osteoarthritis, spinal cord injury (in the absence of sweat
impairment), or aging, or those who cannot participate in regular
physical activity for extended periods. Sauna poses little risk of cardio­
vascular complications in healthy adults, however (Vuori, 1988).
Some contraindications for sauna use have been identified, including
alcohol use, hypotension (especially in older adults), recent myocardial
infarction, unstable angina pectoris, severe aortic stenosis (Eisalo and
Luurila, 1988; Luurila, 1992), and among individuals with altered or
reduced sweat function, which can occur with autoimmune disorders,
spinal cord injury, neurological disorders, and in young children (Saari
et al., 2009; Shibasaki et al., 1997; Swinn et al., 2003; Trbovich et al.,
2020). Decompensated heart failure and cardiac arrhythmia are relative
contraindications. Sauna use in patients with a history of stroke or
transient ischemic attacks has not been studied, so it should be avoided
until the condition stabilizes (Hannuksela and Ellahham, 2001). In­
dividuals with acute illness accompanied by fever or those with in­
flammatory skin conditions should avoid sauna use (Kukkonen-Harjula
and Kauppinen, 2006). Individuals taking any kind of medication,
whether prescribed or over-the-counter, should consult a physician
before sauna use (Kukkonen-Harjula and Kauppinen, 2006).
5.4. Hydration and electrolytes
Proper hydration and electrolyte balance are critical to maintain the
body's fluid balance and to promote normal muscle contractility and nerve
function. As described above, approximately 0.5 kg of fluid is lost as sweat
during a single sauna session. Sweat loss rates may vary according to body
composition, with higher body mass correlating with greater losses
(Podstawski et al., 2014). Accompanying the loss in fluid is loss of elec­
trolytes, especially sodium, chloride, potassium, magnesium, and calcium
(Sawka and Montain, 2000). Skeletal muscle cramps and fatigue are
associated with dehydration and electrolyte deficits. Sauna users should
take care to drink sufficient fluids prior to and after sauna sessions and
should consume electrolyte-rich foods post-sauna use, such as cooked
spinach, avocado, tomatoes, fish, nuts, and seeds (Rodriguez et al., 2009).
Individuals who limit their caloric intake, eliminate 1 or more food groups
from their diet, adhere to severe weight-loss practices, or eat unbalanced
diets that are low in micronutrients may require supplements (Rodriguez
et al., 2009). Alcohol consumption before or during sauna use can cause
severe dehydration, hypotension, arrhythmia, and possibly embolic stroke
and should be avoided (Hannuksela and Ellahham, 2001).
10
Experimental Gerontology 154 (2021) 111509
6. Other heat stress modalities
Other strategies for elevating core body temperature such as the use
of hot-water blankets, hyperthermic baths, heating coils, or specialized
lamps that emit infrared-A radiation in a confined area or chamber may
also have favorable effects on the cardiovascular and central nervous
systems. Hot water immersion, in particular, elicits beneficial effects on
several markers of cardiac health (Tei et al., 1995). For example, hot
water bathing more than 5 times per week was associated with lower
biomarkers of atherosclerosis and lower markers of cardiac loading, a
measure of cardiac function. The temperature and frequency of hot
water baths had dose-dependent effects on improving biomarkers of
cardiac health (Kohara et al., 2018). Hot baths have been shown to in­
crease heat shock proteins, a biomarker for heat stress. One study
demonstrated that waist-down immersion in a 40 ◦ C (104 ◦ F) hot bath
for 1 h increased HSP70 (Faulkner et al., 2017). Hot baths also elicit
favorable effects on the brain, including increased cerebral blood flow,
particularly in the frontal lobe (Watanabe and Yorizumi, 1997).
Furthermore, a randomized controlled trial found that hot water baths
for 8 weeks had a moderate but significant effect on improving
depressive symptoms in participants with depressive disorder compared
to placebo treatment (Naumann et al., 2017). Taken together, these data
suggest that hot water baths may have positive effects on health.
7. Conclusions
Sauna bathing is associated with many health benefits, from car­
diovascular and cognitive health to physical fitness and muscle main­
tenance. It is generally considered safe for healthy adults and may be
safe for special populations with appropriate medical supervision. Heat
stress via sauna use elicits hormetic responses driven by molecular
mechanisms that protect the body from damage, similar to those elicited
by moderate- to vigorous-intensity exercise, and may offer a means to
forestall the effects of aging and extend healthspan.
CRediT authorship contribution statement
Rhonda P. Patrick, Ph.D.: Conceptualization, Investigation, Writing -
Original draft preparation; Writing - Reviewing and editing, Resources,
Supervision; Teresa L. Johnson: Investigation, Writing - Original draft
preparation; Writing - Reviewing and editing.
Declaration of competing interest
Rhonda Patrick, Ph.D., is cofounder of FoundMyFitness, LLC, and
frequently lectures on the science of sauna as a potentially healthful
modality through podcasts, videos, and articles published on foundmyfi
tness.com. Teresa L. Johnson, M.S.P.H., M.A., R.D., is the founder and
president of TLJ Communications, LLC, a provider of science writing and
health communications. Neither Dr. Patrick nor Ms. Johnson profit from
the sale of saunas nor do they retain any ownership stake or other formal
relationship with any businesses involved in or affiliated with sauna
manufacture or commercialization.
Acknowledgements
The authors wish to acknowledge Daniel Patrick for his comments on
the manuscript and Alison Guidry Gates and Dagmar Bouwer for their
assistance on the figures presented in this publication.
Funding
Rhonda P. Patrick, Ph.D. and Teresa L. Johnson receive funding from
FoundMyFitness.com, a science journalism website.
R.P. Patrick and T.L. Johnson Experimental Gerontology 154 (2021) 111509

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